Two More Feet Of Snow Has City Stomping Mad (Cool Snow Sculpture!)

When the weather forecast called for two more feet of snow, someone took that literally and created this really cool snow sculpture.   Two more feet of snow.  Literally.   How cool and creative is that?

Marty's Graduation Picture. He Sure Is a Smart Lookin' Princess

I bet you guys didn't know Marty, our little Italian greyhound Princess, is also a scholar.  Here's a picture of his graduation from Princess school.  He looks pretty good next to my high school graduation picture.

What Are Doctors Looking For When They Look In Your Ears on Exam?

A reader asked me the question:

What are doctors looking for when they look in your ears on exam?

Looking inside your ears is part of the history and physical examination.  Of course the easy answer  for why doctors are looking in your ears is to first answer the question:

What self respecting doctor would bother to look in someone's ears?  

If your doctor does decide they are going to look in your ears, they  are really just wanting to know if the light passes all the way through. If it doesn't, then they usually refer you to an ear nose and throat doctor for an HEENT exam, especially if your doctor is a cardiologist.    Just kidding.  The real answer is to make the patient think they are actually doing something important.  Since you, the patient,  can't see inside your own ears, you'll never be able to second guess anything  your doctor says about the ear exam, even if your doctor is a cardiologist.    If they tell you you have an ear infection and you need to take an antibiotic, who are you to second guess them.  It's not like you can tell anyway.  Plus, looking inside your ears allows the doctor to up-code your visit.  

Does that help?  Anyone else have any suggestions?

911 Communications May Cost You An Arm And A Leg, Even If You're Having A Stroke

It turns out calling 911 isn't free.  Imagine that.    911 communications may actually cost you money.  People who pay taxes aren't the only ones who are fitting the bill anymore.  In some places ambulances are charging fat surcharges for the extra equipment necessary for the ambulance ride?  How much does an ambulance ride cost if you are morbidly obese?  How does an extra $500 in addition to the base rate.
 

But even people who don't require extra equipment will have to start paying extra for the right to make the call to 911 communications.  How much extra?  How much will calling 911 cost in Tracy, California?  Well, if you want to pay a $48 per year fee, you can call 911 communications centers  as many times as you want.  But if you don't want to pay the fee, how does $300 per call sound.  If you're having a stroke, calling 911 communications may just cost you your arm and your leg. 

That's right.  $300 to call 911 communications for an emergency.  Or perhaps the problem is too many people are calling for nonemergency reasons.  If you can't get the frequent abusers who show up at the hospital by ambulance for nonemergent problems to stop calling 911, maybe you can collect their $300 by garnishing their welfare and disability checks.

At some point, our country is going to have to stop excusing the actions of  the economic tax abusers and start implementing personal responsibility with real consequences that hold folks accountable for their actions.   I  think charging  a fee is an excellent deterant to unnecssary abuse of a system that is overwhelmed with nonurgent convenience care.

Social Networking For Hospitalized Patients: Should You Twitter and Facebook Your Disease?

I took care of a young lady the other day whom I admitted for  diabetic ketoacidosis.  She asked me what her bicarbonate level was.  I was a bit surprised since most of the time my DKA patients' don't care what their bicarb levels are.  I told her it was eight.  For the non medical types out there, that's low.  That's critically low.  

I asked her why she wanted to know.  And before she could even get the words out, she had posted a Tweet onto her Twitter acount to update all her friends and family of her impending hospital admission.  I found that fascinating. 

I've been a hospitalist for seven years now.  When I started, my phone couldn't do anything but call people.  Now I have an iPhone that functions like a portable mini computer filled with wireless internet, 3G high speed data transfer, instant weather, text messaging, camera, GPS maps and 100,000 applications at my finger tips.  When I was a medical student and resident, my hospital wouldn't even allow cell phone usage near patient floors for fear of interference with wireless hospital telemetry boxes and ventilator equipment.  How silly that sounds now. 

I can't even imagine what I'll be carrying around seven years from now.  For my patient, she chose to use her phone to access her Twitter account to let the world know about the state of her health.  I'm sure she also updated her  Facebook status before I was done writing my hospital admission orders.

While many  people worry about the privacy of their health problems, many more are turning to social networking sites to liberate themselves from the secrecy of their health problems.  I think social networking sites will  revolutionize a public's perception of depression and disease  and help patients focus on recovery rather than secrecy.  There is a large amount of liberation and relief that comes with  discussing  your medical problems with others around you.  

As many of you know, Mrs Happy and I have been going through a fertility process for the last several years.  I made a conscious choice early on in my blog to be honest and open about that process.  For many couples, problems with fertility cause them to shut down in a shame of secrecy.  I think that's sad.  There are probably millions of couples out there just like us who struggle with problems of pregnancy.  I can't think of a single reason why the process should be buried in secrecy.  

Perhaps someday, hospitalized patients will have 24 hour immediate access to social network portals at their bedside, with live streaming updates and real time recording of their discussions with doctors and nurses to keep friends and families in tune with what's going on.  Perhaps this process will also reduce physician risk  and malpractice by better documenting discussions with patients and families who feel they were not given appropriate care. 

Perhaps someday Twitter will create a secure Tweeting network for doctors and nurses to communicate with patients and each other.  Perhaps someday Happys' hospital system will link directly with a patient's portable health site on Facebook so they can take their hospital records with them without doing a thing.  

As technology expands exponentially and the abilities of today's computers are dwarfed by the  next generation processors, hospitalist  medicine and social networking sites such as Twitter and Facebook  may someday find themselves partners in a unique opportunity to provide patients and the families of patients  with better quality of care, improved efficiency, and better real time communication of real time medical care.

Perhaps someday I could Tweet a negative CT result to the patient as soon as I get the result, instead of having them wait until the next day wondering for hours whether they have cancer or not.  Perhaps someday, I could Facebook the daily chest xray picture to  an anxious man wondering if his lungs are getting better or worse, so he's prepared for my daily rounds and discussion.

The possibilities are endless.  Social networking for hospitalized patients offers a unique opportunity to reduce costs, decrease anxiety  and improve communication between doctors, nurses, patients and families for people who have nothing better to do than Tweet and update their Facebook status between biopsies, x-rays and lab draws.

Automatic Pill Dispensers Go Low Tech, But Brilliant None The Less

When you think about automatic pill dispensers, I'm sure you think about something with batteries or a plug in that organizes all your pills for the day.  That's all fine and dandy, but that's not what old people want these days.  In my experience as a hospitalist, my patients often complain about the massive size of pills they are forced to swallow.  Why can't they have an automatic pill dispenser that helps them swallow their pills in the hospital instead of trying to put ten pills under their tongue at one time and gagging with every swallow?

Read On

Home Birthing Experience Should Not Turn Women and Midwives Into Criminals

Some women want to go through a home birthing experience.  Before the creation of western style hospitals, women all across the world routinely had a home birthing experience.  They had no other choice.
 

Many states have banned the practice.  They have created laws that turn midwives and other health care professionals into criminals for assisting mothers with their home birthing experience.  I think that's a shame. 

Birth is a natural process.  In selected low risk populations, the risk of adverse outcomes with a home birth are no greater than the risk of complications in a hospital.  In fact, I would argue that complications in a hospital might be higher because of the chaos generated by multiple patients being cared for by multiple nurses and doctors.  

I know I'm going to get some slack for this from the medical professionals out there, but if you are going to be intellectually honest, you have to be able to show me that low risk mothers have a higher rate of complications in a home birthing experience than they do in the hospital.

The argument generally given by doctors against allowing certified midwives to practice their skills in the home environment is that should a complication arise, the risk of a bad outcome could be devastating. 

That statement is entirely true.  That statement is also true for a complication within the walls of a full service 1000 bed state academic institution with 24 hour in house physician coverage.  The fact remains that we don't practice medicine with perfect probabilities.  We practice medicine by analyzing the risks and benefits of everything we do. 

For some low risk mothers, the benefit of a home birthing experience may far outweigh the minimal chance of a bad outcome.  I don't know any mother or midwife that would risk the life of the child by undergoing a home birth experience in a high risk setting.  

I like to think of a home birthing experience as similar to treating a pneumonia as an outpatient.  When I am asked to admit a patient to the hospital for pneumonia and I go to evaluate the patient in the emergency department and I make a conscious medical decision to discharge them and to treat them as an outpatient, I am making a clinical judgment as to the high probability of a good outcome outside the hospital.

Not every patient that gets pneumonia needs to be admitted to the hospital.  There are in fact published guidelines that establish thresholds of risk for inpatient vs outpatient therapy.  We could very clearly apply the same evidence driven guidelines to a home birthing experience.  

There are many healthy mothers out there who have previously experienced a hospital birth and wish to proceed with the natural home birthing experience.  We already know that mothers without risk factors for complications have no higher risk out of the hospital than they do in.  To deny a mother the  right to experience the natural birthing process is a shame.  It can turn mothers and providers of natural birthing care into criminals.

Mrs Happy told me about a friend of hers who recently went through an uncomplicated home birthing experience with the help of some nameless providers of care.  In Happy's state, it is apparently illegal to have an assisted home birthing experience.  You can have an unassisted delivery because, no one could ever prove that little Jimmy just popped out so quickly.  But try and get someone with any medical experience or training to help you with your home birthing experience and they could lose their license.  

The fact remains there are now birthing centers in 33 states of our country.  They allow low risk women to experience birth the way nature meant it to happen.  Not the medicalization of birth the way doctors have turned it into.  Home births are a natural extension of this demedicalization.

In a bankrupt health care system where no one can afford their premiums, where corporations are removing health care benefits from their balance sheets and where more and more people struggle to make ends meet in a premium environment that is out of control, I welcome any form of health care intervention that has equivalence in outcomes at a reduced cost, without destroying the safety net of a city's hospital system.  

If a low risk mother wants a home birthing experience, I think it's sad that they are forced to go underground to experience the most natural process in the world. All medical professional societies that prevent women from experiencing the beauty of a home birthing experience should be ashamed of themselves.  It doesn't surprise me that all professional hospital and medical societies speak out against the home birthing experience.  It's not an issue of quality.  The data just doesn't support that.  It's an issue of money and protecting the status quo. Pregnancy should stop being treated as a disease. 

Grand Rounds at the Whistleblower MD

Go check it out.

Internal Medicine Opportunities: Three Words: Patients of Walmart

If you are an internist or a hospitalist looking for internal medicine opportunities to increase your  bottom line, I have the perfect business opportunity for you.

Walmart.  It's a physician marketing gold mine.    Yes folks, you heard it here first. Walmart is no longer just the place where nurse practitioners can practice their life long dream of refilling thyroid scripts and generating Wellness plans for healthy 45 year old mothers with no medical problems. Walmart is not just the place where healthy middle class mothers pop in for some prescription strength Zyrtec to treat their seasonal allergies.  Walmart is about the walking wounded.  Walmart is about the poorest of the poor.  Walmart offers the perfect patient population for internal medicine opportunities.

I've been thinking  about my new internist driven Walmart model of care ever since a patient of mine let the rabbit out of the hat.  What was this long regarded secret, known only by the chronically sick, chronically debilitated, and chronically poor?   

Happy:  What do you do for fun since you are limited by your six liters of continuous oxygen?

Stranger:  I have my son drive me to Walmart and I cruise around the isles in their electric scooter with my friends.   With my oxygen on all the time, there isn't alot I can do.  So me and a couple friends go scootering down at Walmart three times a week.  

My jaw dropped.  Of course.  Walllmmmmaaarrrtttt.  That place is a gold mine of internal medicine opportunities.  Why hasn't any internist thought of this before?

Walmart is where all the poor and disabled people go for their basic needs.  It's a one stop paradise shop.  It has everything.  Canned soups.  TV dinners, Cigarettes. Flat screen TVs. A bathroom.    Walmart has everything this population could ever want.  Why not their daily entertainment as well?    It's their social Mecca.  They have handicap parking spots by the dozens.  Walmart charges no entry fee to get in.     The cigarettes are cheap. Dozens of electric motorized scooters line the isles fully juiced and ready to go.      Walmart has everything the chronically disabled, smoking, oxygen dependent, wheelchair bound COPDers could ever ask for.

Who knew there were scooter gangs congregating in the halls of Walmart?  I just figured they were all  looking for the buy one get six tube socks free deal of the week.

It's time internists take control of their destiny.  Internist education is far too superior to be  wasted on the minute clinic model of care.   What we do takes a far greater understanding of the human body.  We hold a knowledge that can only be appreciated by people who have experienced the rigors of the medical school education.   We are far too qualified to provide such a service by itself. No folks, that's not for us.  However,  Walmart does offer internal medicine opportunities that are limited only by our imagination.

The halls of Walmart proudly present to us the Patients of Walmart (PoW). The internal medicine opportunities are obvious.   These are complicated disease ridden patients who come scootering  for a nice Saturday stroll with their friends.  If they can't come to your office to get the care they need, it's time that we, as highly trained internal medicine physicians take our services to them.  If the nurse practitioners can do it for the healthy moms and kids out there, there's no reason we can't expand our internal medicine opportunities as well.

It's going to be  called the Doctors of Walmart (DoW).  The model is simple.  DoW will require at least four doctors to start.  Expansion will happen quickly after that.  It always does.    There are just too many PoW's  for that not to happen.  What is the secret to success for DoW?

It's all about location, location, location.  Four internists will set up shop in key markets across the Walmart experience.  One doctor gets the cigarette checkout stand to corner the COPD dyspnea  market.  Another sets up shop in the boxed and canned goods isle to take advantage of decompensated heart failure PoWs.  One doctor heads for the electronics, gaming and cell phone department because that's where all the poor and disabled people spend their discretionary free government money.    And last but not least, one doctor sits inside the attached McDonald's that seems to be competing, and competing well I might add, for the scootering public.

Your patients are fully insured with  Medicaid or Medicare.   They're all on disability.  They all have free government money just waiting to be spent on something.  For internists, this is an opportunity of a lifetime  to capture the enormous economic potential hiding in the Patients of Walmart.

Once you've billed their insurance, you can use the chiropractic marketing techniques you learned to sell them stuff they don't really need, like designer ostomy covers and expensive vitamins (but make sure they don't require Medicaid preauthorization first).  Once you've entered their psyche and you've associated your doctoring skills  with the  fun of their Saturday scootering stroll with their friends, you'll have a revenue stream for life.

Internal medicine opportunities are everywhere.  You just need to know where to find them.  The Patients of Walmart offer the perfect opportunity for Doctors of Walmart to exploit this haven  of free government money and free entertainment to finally associate your internal medicine skills with something fun and exciting.

And it's WIN-WIN

Math Humor: Never Drink And Derive

That's just some good math humor. Never Drink and Derive 

Happy Hospitalist's 1991 High School Graduation Picture

I graduated from high school in 1991.  I have my 20 year high school reunion coming up and was looking at some old yearbook pictures when I came across my high school graduation picture.

What do you think?  Pretty sexy, huh ladies?

I Put 100% of my 401K Into Cash Today

Today I've done something I have never done before.  I put 100% of my 401K into cash.  I have no faith in the currently destructive political-economic environment.

What is everyone else doing?

Doctors' Income and Doctors' Hours Worked: Trends That Should Frighten You

I suppose you're wondering what doctors' income has done over the last ten years.  Today I read a report that inflation adjusted doctors' income has declined by 25% between 1996 and 2006.  That means your doctor earns 25% less today than they did just a decade ago.

Some people feel doctors make too much money.  If you went to college and joined a company that said up front  you would be paid 25% less in a decade than you were paid on the day you were hired, would you join them?  I'm sure many people would find that thought obnoxious.  But that is the current reality of physician medical specialties.

I also learned from the Journal of the American Medical Association that the average physician is reducing their work hours per week.  From 1996 to 2008, the average physician cut their hours from 55 hours a week to 51 hours per week.  That is the equivalent of losing 36,000 doctors in a decade.  

Why are physicians working fewer hours, a trend unique to doctors?  The conclusion was reduced pay.  Physicians just don't seem inclined to spend long hours in the office and hospitals to sacrifice their family life for the life of their patients when the the economic reward of doing so just isn't there.  

I've talked with many subspecialists at Happy's hospital about the declining payment for their efforts.  They all tell me exactly the same thing.  They are going to work less and limit their hours as payment reductions come down the pipeline.  The evidence is clear.  Doctors are not martyrs.  When they  sacrifice their lives for their patients, their families suffer. If you pay them less,  they won't put up with that lifestyle anymore.   As one physician was quoted as saying

"If you get paid less...

If you think the doctor shortage is rough now, wait until it takes 3 months to get into the cardiologists office or two weeks for the pulmonologist to call you about your lung biopsy result.  If you aren't going to pay a physician commensurate with their education, a field with more educational sacrifice, by far,  than all other fields in professional education, you will get what you pay for.

Physicians working 40 hours a week, taking no hospital and no weekend call.  You will get a nation of patients being cared for by nurse practitioners wondering where all their back up doctors went.   We see it already in primary care.  That is your barometer of what is to come for all doctors. 

We get exactly what we pay for.  As for hospitalists, I have to admit, we have left the constraints of the Medicare National Bank and our field is the fastest growing medical specialty in the history of medicine.    The subsidized model of hospitalist medicine the the best WIN-WIN alliance ever. You'd have to be a blind squirrel looking for acorns not to see the writing on the wall.  Or you'd just have to support the current political policy positions of the AMA  and you'll get the same result.   

Someday I'm going to be forced to take a   weekend class on heart catheterizations and bronchoscopies and I really will have to tell a patient that this is only my second time doing this.  All the other doctors are at home playing with their kids on a bright sunny day.  And none of them find coming in to work to be much worth the effort anymore.

Record Number of Hospital Visits?

I don't know what the record number of hospital visits are out there are.  But I saw a guy in the ED the other day that had 240 ER visits in the last six years. 

Read On

Medicare Medical Necessity Sham: Don't Fix What Ain't Broke

The Medicare medical necessity sham is at the root of all that is evil with our Medicare National Bank.  Medicare medical necessity is the threshold used to determine if Medicare, the ultimate third party insurance company, will pay for any visit, procedure or bloodless surgery.

You can't just go to the doctor and talk about the basketball game last night and expect any insurance company to pay for it.  Medical necessity is the process by which Medicare determines that the office visit (Evaluation and Management or E&M) was necessary or if the surgery or procedure or laboratory was medically necessary.

Going to the doctor for chest pain is medically necessary. Chest pain has a CPT code.   For every contact you have with your doctor, a  CPT medical code is submitted to your insurance company by your doctor.  That CPT code must have an ICD 9 code attached.  That's how Medicare medical necessity is determined.  There is no ICD 9 code for talking about the basketball game.  There is an ICD 9 code for chest pain.

But Medicare medical necessity doesn't work.  Why?  Because any doctor could make any office visit or any procedure or any surgery medically indicated if they document the right words in the right place. We do too much in this country.  Some of it is legal driven.  Some of it is money driven.  Doctors get paid to do more.  We don't function like farmers.  We don't get paid to let our patients sit idle.  Some of it is ignorance driven by both doctors and patients.  As care gets more complicated, the permutations of outcomes can become overwhelming.  Sometimes doctors simply don't know what they are doing.  Some of it is IT driven.  It's easier to order another  x-ray than to wait for the report to show up tomorrow.

There are lots or reasons why we spend too much money on health care in this country.  But the fact remains, to order anything and have it get paid for by Medicare, you must have Medicare medical necessity.  After talking with a garden variety Medicare patient the other day, I have come to the conclusion that the process is a sham.  And the only way to curb health care  costs is to bundle the care.   What was my shocking conversation?  Read on...

Mrs Happy and I got invited to our neighbor's first Birthday party.  It's there where I met grandpa Frank.  Frank has been in the insurance business for over 30 years.  He told me that in his experience at least 15-20% of all medical claims were probably unnecessary but that no insurance company has the resources to go through all claims with a fine toothed comb.  And the result is simple: costs rise and premiums rise. The more it costs to take care of patients, the higher the premiums will be.  

That doesn't surprise me.  It makes the Medicare medical necessity sham even harder to tweak out. Having an indication  to do anything is easy.  Whether that indication is a bending of the truth or whether it represents reality is hard to figure out when you're looking at billions of pages of claims every year.

While talking with Frank, I learned that he always got a full physical exam every year for the last 30 years from his private insurance company. I told Frank that there is no data to suggest that having a yearly physical exam has ever been shown to improve outcomes.  If anything, it is a chance to keep in touch with the medical system and to make sure that all preventative recommendations are up to date.  But the act of a yearly physical exam has a very low yield for discovering critical pathology in the asymptomatic patient.  

He told me he tends to agree with that statement ever since one of his insurance executive bosses had a company paid for three day stay at the Mayo clinic for an executive physical.  Three days.  Unbelievable.  After three days of extensive testing he was given a clear bill of health.  I have no idea what they could have possibly done over a three day period, but this man had a massive heart attack and died as he was getting in his car to drive away from his clean bill of health.

Yearly physicals are not worth the time and money if you're looking for pathology.  They simply don't work and are not cost effective in asymptomatic patients.  If you are a smoker, it's about talking about quitting.  If you are a drinker it's about talking about quitting.  But if you're asymptomatic and up to date on all your preventative recommendations, the visit will unlikely offer you any benefit.

The same thing goes with yearly labs.  Even mama and papa Happy get their yearly labs drawn at a local lab fair, often paying cash.  They are not medically necessary.  Drawing yearly CBCs and basic electrolyte panels and TSHs and liver panels and sed rates and cholesterol panels have never been shown to have benefit  on a population basis.  Of course, if you are that one in one thousand patients who happen to find a myeloma from asymptomatic screening you would argue otherwise.  But I would also suggest that the lead time bias during your asymptomatic state of diagnosis would not likely have changed the outcome. 

The same lead time bias of detection goes for yearly chest x-rays or even CT scans.  There is no reason in the world to get a chest x-ray if you are asymptomatic.  Even if you are a smoker.  People who believe they get benefit are fooling themselves out of fear of the unknown.  There is no reason to get a CT scan.  There is no reason to do any evaluation, even if you are a smoker.  

Of course, if you are a smoker who discovers a lung mass on routine screening, you would argue otherwise.  I would suggest again however that a lead time bias would not likely have changed the outcome. of early detection for lung cancer.  The data just doesn't prove otherwise.  By the time a tumor can be visualized, it is years in the making.  Your lead time bias of a few months before symptoms arrive will not change your outcome.  And it exposes you to unnecessary radiation and potentially deadly complications of asymptomatic common wear and tear.

The same goes for asymptomatic carotid artery stenosis and peripheral arterial disease.  The United States Preventative Services  Task Force recommends against screening for either in asymptomatic adults.  But you can find vascular surgeons and hospitals all across this country charging folks $100-$200 dollars cash for screening.  The reason no insurance will pay?  They are medically unnecessary and feed on the fear of the unknown.  

Only abdominal aortic aneurysm got a one time screening recommendation for adults aged 65-74, and then only for smokers.    And the USPSTF specifically recommends against  screening  low risk asymptomatic adults for coronary artery disease with EKG, stress test and electron beam CT (EBCT) for calcium scoring.

So I was disappointed to learn that one of my most respected internists in Happy's community has been doing a yearly chest x-ray and EKG on Frank for years and years and years.  I asked Frank why?  He's never smoked.  He has no cough.  He has never had angina.  He has no symptoms of pathology at all.  He exercises and has no issues with his cholesterol.  He is a healthy adult specimen doing everything right.  He is the perfect patient.

But his outpatient primary care internist has been doing an office based EKG and chest x-ray for decades and Frank just thinks that's the way it is.   I asked Frank if he feels good about the tests always being normal.  He said yes.   It's reassuring he said.   I have strong feelings about my  displeasure with doctors who own their own equipment and self refer patients for evaluations that get paid for using that equipment.  

There is an  inherent conflict of interest in any relationship between doctor and technology where the doctor gets paid to do more using the technology they own.  Medicare medical necessity is a sham.  We simply can't differentiate between real leather and the fake stuff anymore.   Primary care won't make a lot of money getting paid for thinking.  But they can if they own their own ancillary equipment.  Just like every other medical specialty on this earth.  Then Frank dropped another bombshell.

Frank received one of those EBCT cardiac calcium scans five years ago and his outpatient internist recently told him it might be time for another one. 

My jaw dropped to the floor.  I told him about the massive dose of radiation these things have been shown to expose patients to.  Asymptomatic patients.  I asked him if he felt relieved when his last one was pretty negative.  He said yes.  Once again, it's reassuring.  I told him what he should expect to happen to him if his second EBCT scan came back abnormal.  

Here's a functional, healthy, asymptomatic guy who will go in to get a  CT scan that exposes him to large radiation doses.  If the test is abnormal, he will likely get a heart catheterization, exposing him to more risk (dye allergy, groin pseudoaneurysm, renal failure, coronary dissection).  If a lesion was found in this asymptomatic  gentleman, what will happen to Frank?  Will Frank get a stent?  Probably so, despite the compelling data suggesting that stents offer no benefit beyond medication therapy in asymptomatic patients.  

So I told Frank, if he gets his calcium scan, heart catheterization and then ends up with a stent, he'll have to go on Plavix, which will create risk where no risk previously existed..  We would have created disease out of health and turned Frank from the perfect patient into the perfect patient for a hospitalist. I am the last person in the world Frank should ever have to see,  especially when he does everything right.   It's his doctors that have failed him.

This is the problem with American health care.  None of this should be paid for.  None of this madness is indicated.  But every last bit of it gets  paid for.  All of it.  Every time.    I asked Frank to ask his internist how he gets the yearly chest x-ray, EKG and labs to get paid for if he has no ICD code to bill it under.  I'm sure there's a code.  I'm sure it meets Medicare medical necessity somewhere.    Because it always does.  And as Frank the insurance guy admits, there aren't enough claims reviewers to go through charts with a fine tooth comb. 

I am extremely disappointed in the actions of this community internist.  I have a high respect for his capabilities.  But the fact remains, none of this should be paid for.  It's medically unnecessary, but yet it is.  Because it  will always be necessary.  And the only way to get this  excess out of the fee for  service system that is American health care is to stop paying for it.  And the only way to do that is not to hire one million government workers to comb through doctor charts with a fine tooth comb.  The solution lies in bundling the care.  If a doctor is making money on their x-ray machine or their EKG machine, or their lab equipment, they have every incentive in the world to maximize Medicare medical necessity.  And most patients find relief in the comfort of knowing that everything came back normal. 

All thirty chest x-rays were normal

All thirty ECGs were normal

All thirty years worth of labs have been normal.

And yet, every year, the comfort of knowing it's still normal supersedes the knowledge that for thirty years Frank has received care that was medically unnecessary, and yet fully paid for by his premiums, and now the Medicare National Bank.

And that's why nobody can afford health care.  Don't fix what ain't broke.  It's time to abandon the idea of Medicare medical necessity and actually pay for care that is needed.  What we need and what we get are two incongruent pathways.   Bundled care fixes that instantaneously.

Cookie Bouquet Basket From Nurses With Love

Here is a picture of a cookie bouquet basket made by one of Happy's hospital nurses. This is apparently how you test out a new cookie recipe these days. You don't just mix up cookie batter, bake them and throw them in a plate.  No.  These days, you create elaborate cookie bouquet baskets.

Read On

Herd of White Deer In Wisconsin

Check out this PBS documentary clip of the herd of white deer in Wisconsin.  Now that's just cool.  I wonder if the other deer discriminate against them.

Refueling Airfcraft Over Iraq: Video Taken Just Feet From Fighter Jets

This is really cool.  Have you ever wondered what it's like to be at the front and center of a refueling mission for F/A-18D Hornet fighter jets?

Air & Space Smithsonian takes us up close with  embedded photojournalist Ed Darack who captured this amazing video of fighter jets refueling over the Anbar province in Iraq.  Enjoy the skills.

Disposable Face Masks By Disney : Where Dreams Do Come True

I just got back from Disney World not too long ago.  They are hurting for business down there.   So it doesn't surprise me that Disney is expanding their revenue operations into disposable face masks and other hospital supplies.  I took this picture of a disposable face mask with Disney characters in Happy's emergency room.  Right next to the hospital stickers and the designer ostomy covers. 

I'm waiting for Disney to expand their empire into designer progress notes and order sheets for hospitalists everywhere.   For the surgeons, perhaps a nice assortment of fashion  medical exam gloves, designer surgical scrub hats and scrub gowns, booties and maybe a cartoon hair net or two.  

I'm telling you, hospitals need to expand their revenue operations beyond the Medicare National Bank. They need to take advantage of  chiropractic marketing techniques and the magic of Disney marketeers.  If Disney can scam their way into the hospital supply market and find hospitals willing to pay extra money for designer disposable face masks, I say it's time for hospitals to do the same.  It's time to put these techniques into action and squeeze more revenue out of rich  patients who use their social security checks as their vacation fund. These are the people willing to pay extra for things they don't need.  There are tens of millions of these hospitalized patients every year.  And I know this because I take care of them every day.  

I'm thinking in addition to pet therapy dog service , hospitals need to offer a nice assortment of designer hospital gowns, bottled water, premium shampoos and soaps for a premium price.   Disney is the master of squeezing every last drop of money out of your wallet by creating an experience unique to Disney.    It's time hospitals used the same marketing techniques of Disney to generate additional income by creating a magical environment where dreams do come true.  Hospital theme parks.  That's the future of hospitalist medicine. 

And just think.  It all started with a disposable face mask.

Green Urine? Is This a St Patrick's Day Trick or Medical Mystery?

So I'm admitting a 103 year old lady who fell at home and is too weak to go home. In the words of our excellent ER physicians, hospitals with emergency rooms  have famously become known as the defacto senior safe haven drop off point for elderly in our country. 

As I'm just finishing up her hospital admission,  I hear a commotion in the background.  

ED doctor:  I wonder what's going on with that guy.    He's got green urine.  

Read On

Naming Roads, Streets and Highways After Celebrities and other Famous People Hits Home

You've all seen the roads, streets, highways, airports and federal buildings renamed after prominent local or national politicians, business owners and philanthropists who donate a lot of money.  You can add a medical blogger to the list of famous people worthy of having a road named after them.  I don't have a lot of money, but my blog is apparently worthy of a renaming project.    

A reader sent me this picture of an exit near Kansas City.  Clearly, The Happy Hospitalist Expressway is taking off.  If you don't want to be left behind, I suggest you tag along for the ride,  keep your eyes and ears alert and attentive and absorb all that is my knowledge of hospitalist medicine.

And if you're going to travel on my HH expressway, please don't litter.  

Before I Was A Doctor

Your doctor was not always a doctor.  Before sacrificing their life to a medical school education they were lots of other things as well. 

Read On

Swallow Syncope or Vaso-Bagel Syncope As An Uncommon Cause of Passing Out

So I got asked to consult (CPT 99253, 99254, 99255) on a patient admitted with swallow syncope. I found that fascinating.  Swallow syncope?  I'd never heard of that before.  Syncope is one of the most common admitting diagnoses I do.  As  internists, we often do way too much in the evaluation of syncope.

Syncope is another word for passing out due to a global loss of perfusion and oxygenation to the brain.  Many studies have shown the very low yield of doing extensive work ups for syncope.   A lot of the work up is based on old habits and fear of the unknown (defensive medicine).  Often times hospitalists, internists, cardiologists and other subspecialists will order a vast array of testing for syncope, much of which is rarely diagnostic, except it allows us to say to the patient that "everything looks normal".

I find the shotgun approach to syncope to be of extremely low yield, and very expensive.  I would say it's one reason why medical care is so expensive.  The shotgun approach is not evidence based.  It's often fear driven. We need to let our history and physical examination guide how we work up syncope.  This is one situation where listening closely to what the patient has to say makes all the difference in the world.

Was there a postictal state of confusion?  Was there loss of bowel or bladder dysfunction or a tongue laceration.  If not, doing an EEG is rarely appropriate.  Is there a murmur or a  history of cardiac disease, other rhythm  or valvular disease  or an abnormal EKG?  If the answers are no, a cardiac echo is unlikely to offer you any explanation for syncope. Even telemetry is of low yield in a patient with a normal looking EKG and cardiac exam. Does their carotid massage induce a bradycardic response?  That's an often forgotten initial  physical exam technique.  

As for doing carotid dopplers, these are probably one of the biggest waste of time, money and resources in the evaluation of syncope.  To pass out, you must have global hypoxemia.  That means to have carotid obstruction cause syncope, you must simultaneously cause bilateral carotid occlusive disease.  That never happens.  Doing carotid dopplers in a patient with syncope is rarely appropriate.  If you're evaluating a patient for stroke, fine.  For syncope, carotid dopplers just aren't indicated.

Sometimes a patient with a venous embolism (or pulmonary embolism) presents with syncope.  You should always keep that diagnosis in the back of your mind when you have nothing on history or physical to guide you to an etiology.  Would I do a CT scan of the chest in everyone with syncope (especially knowing what we know about CT scan radiation exposure)?  Of course not. So why would we do an EEG, echo and carotid doppler on a patient who's subjective and objective data does not suggest they are necessary.

So what does help in the evaluation of syncope?  Doing orthostatic blood pressures help.  I want to know what the patients blood pressure and pulse is in the laying or supine position, the sitting position and the standing position. A drop in systolic blood pressure of greater than 20 mmHg or a drop of diastolic blood pressure greater than 10 mmHg is indicative of orthostasis.   I don't know how nurses are trained to get orthostatic blood pressures, but I have to always remind them to get a pulse with the blood pressure.  A patient's pulse response to orthostasis is important for me to evaluate the drop.

Also don't forget about the carotid massage.  Can you induce a significant bradycardia by rubbing their carotid artery?  If so, they may have a sensitive carotid body and may need further cardiac workup.

Most of the time syncope is a benign situational vaso-vagal response to some emotional stimuli.  Usually it's an old guy with urinary retension or difficulty having a bowel movement.  Sometimes folks pass out in church.  We call that church syncope, or religious syncope.  It's a benign process.   Sometimes we prescribe beta-blockers and support hose and tell patients to avoid the triggers.  But it won't kill you, unless you happen to be driving at 75 miles an hour when it hits. Or you crack your head open when you hit your granite countertop.

Orthostasis and vaso vagal syncope are probably the two most common causes of syncope.  For orthostasis a volume expansion will usually fix the problem.  Sometimes the patient may have adrenal insufficiency and the use of fludrocortisone or hydrocortisone may be indicated (commonly in diabetics and Parkinsons patients ).

But this patient had something I'd never heard of.  Swallow syncope.  Apparently, every time they took a large gulp of soda,  they passed out.  They've done it in the past.  They did it in the hospital.  I saw the telemetry.  Impressive to say the least.  Almost like this adenosine pause.  When your ventricles stop pumping blood to your brain, you lose your cerebral perfusion.

And you pass out.  In this case, swallow syncope gives the patient a form of vagal mediated bradyarrhythmia or atrioventricular block.  According to one pub Med article, this can happen with cold carbonated beverages or with large boluses of food, termed the Vaso-Bagel syndrome.  

So the next time you have a patient with syncope, stop doing carotid dopplers, EEGs and echos.  Check their orthostatic blood pressures, rub their carotid and ask them about their relationship to food and drink.  And you might just diagnose them with swallow syncope or the Vaso-Bagel syncope.

How wild is that? 

Welcome To The Grand Rounds Hospital Version

over at the ACP Hospitalist blog.  Go check it out.

How To Convince Your Hospitalized Patient To Take Their Medication

As a hospitalist I sometimes come across patients who, for what ever reason, refuse to take the medications prescribed by their in-patient doctors.  Some patient refuse out of fear.  Some doctor told them years ago that taking medication X would make them worse.  Some patients refuse out of ignorance of their disease process.  Most of the time however, they just don't understand why the medication is necessary.  Some patients just refuse out of stubbornness.  And some patients refuse because they have a really good reason.

Read On

Ostomy Covers and Bags (Ileostomy, Colostomy): I Bet You Didn't Think Of This

Ostomy covers are just one in a long series of supplies necessary in the care of colostomy and ileostomy patients.  The words ileostomy and colostomy refer to the procedure ending up with a bag coming out of the abdomen  that fills with stool.  They are usually placed in folks who have lost the distal portion of their colon (colostomy) or when the entire colon has been removed or when the small bowel must be diverted (ileostomy).   They can sometimes be reversed (called a take down) when the underlying reasons for placing them are fixed (such as massive decubiti ulcers).

All ostomy sites, whether they are ileostomy or colostomy sites, must be protected to ensure their survival.  Ostomies require care to prevent ulcers at the exit site.  They can get ischemic and and swollen and obstructed.  Sometimes they need to be surgically revised.  They need to be kept clean at the surface to prevent infections.  They should be kept dry while in the shower or bath.  

And that stuff costs money.  You can find ostomy covers and ostomy bags in all assorted sizes and colors at online  stores or at your local medical supply company.  In fact you can even find designer ostomy covers and bags.   Maybe this represents a growth opportunity for  the higher end designer bag makers Coach, Kate Spade and Loui Vitton.  

Designer ostomy covers and bags could take future growth projections for these higher end bag makers to a  whole new level.  The growth opportunities are enormous for an aging and wealthy population who cares less about the bag on their shoulder and more about the bag on their belly.

But don't forget about the little ones out there.  Perhaps even Disney could market Minnie ostomy covers and bags for the little kids out there stricken with illness.  You could have the best first grade show and tell ever with your Goofy ostomy cover.  Most kids bring a trinket .  Your kid shows his Goofy ostomy cover.

Think of the other possibilities.  Hospitals could throw designer ostomy cover and bag parties as a new way to fund their daily operations as the Medicare National Bank goes belly up.  Or perhaps, in addition to pet therapy dogs, an ala carte menu of optional services for patients could include offering them special ostomy covers for their ostomy bags.

Look at the spirit of cooperation between hospitals and hospitalists and you can understand the power of market economics in medicine.  Many doctors are troubled by today's EMRs.  They don't know it yet, but someday EMRs will be their saving grace.  And it has nothing to do with  making medical care better or more efficient.  In fact, as insurance cheapens the value of medical education,  EMRs will become nothing more than a tool for direct marketing.

Medical doctors could go the way of chiropractic marketing and show up at trade shows and State Fairs peddling a whole array of ostomy covers and ostomy bags to a public willing to spend their money on everything but actual health care. Or better yet primary care doctors, internists and gastroenterologists could give the knock off jewelery and purse parties a run for their money.  These doctors  have a focused clientele right at their finger tips.  If they have a patient panel and an EMR, they have a whole new and exciting business opportunity just waiting for them.

They just have to run an EMR comparison for those patients with an ostomy and send them an invitation to their private party selling  designer  or knockoff designer ostomy covers and bags.   You think Pampered Chef parties are out of control.  Wait until you have a million doctors inviting you to their ostomy cover parties.   Just you wait.  It's going to happen.

I don't think anyone in Washington thought of  the unintended consequences  of health health care reform and of a declining Medicare payment model coupled with  the explosion of EMR technology.  Doctors are business owners with an entrepreneurial spirit.  They will always search for alternative sources of income as insurance decimates their bottom line.  Third party insurance companies just don't want to pay for health care anymore.  I witnessed that first hand with my physician review experience. And selling ostomy covers is just one way  for doctors to survive.  But it won't stop with colostomy covers and ileostomy bags. 

Someday you'll have pulmonologists using their EMR  for direct marketing of their designer tracheostomy parties.  You'll have vascular surgeons using their EMR for direct marketing  of their  designer stump parties.  You'll have ophthalmologists taking up designer eyeball tattoos with the help of their EMR.  And you'll have primary care doctors doing botox.  Oh wait, they are already doing that.   

That's the future of the EMR.  It has nothing to do with medical care.  In fact,  the future driving revenue for doctors won't be medical care at all.   Insurance killed that idea.  It will be medical supplies.  Instead of using the EMR to streamline health care, doctors will use it to data mine their patients for the direct to consumer advertising and marketing of goods and services.    You heard it here first.  You thought the drug companies were bad.  Just wait until doctors figure out the power of the EMR.

The whole idea of doctors using their office and patient panel as a direct marketing force de jour lies on the premise that patients are more willing to pay for things than for service.  And that's true for most of them.  You see them pulling up in their full sized SUVs with the shiny 26 inch rims, their smart phones, their $200 jeans and their cigarettes sticking out of their  designer purse.    You know they're willing to pay for image.  But they won't pay a $10 copay to evaluate their diabetes, heart failure, COPD, atrial fibrillation, high cholesterol, leg pains, dizziness, shakes, dry skin, diarrhea, gas, rash and sore throat all in one visit.   You want to survive the future of health care?  I suggest you get yourself an EMR and start selling something tangible.

And for the patients who don't want anything to do with designer ostomy covers?  What do we do about them?  How do we make money on them in the future?  We don't.  But we take great pleasure in discovering the lengths people go to save a buck.  And we enjoy the creative nature of the human mind.  I like the awesome guy who made his own designer ostomy cover  (actually for a urostomy) by cutting out the back side of a bottle of liquid laundry detergent.  I suppose you could say his ostomy will never get dirty.  Perhaps this guy should start his own business selling ostomy covers to poor people, so he can then buy one from you at your exclusive invitation only ostomy covers party. 

Now there's a thought...

Neck Exercises To Do While Sitting In Front of Your Computer

Do you find your neck getting stiff and tired while sitting in front of your computer all day?  It's time to suffer no more.  We put sequential compression devices on patients to prevent deep venous thrombosis after long periods of hospital immobility.  Our neck is no different.  It needs to keep moving.  So here are the perfect neck exercises to do while sitting in front of your computer.  Click on the picture below to enlarge the view and exercise your neck at least three or four times an hour. 

Weight Loss Options: The Greatest Fail Ever In The History Of Fat

What are some excellent non surgical weight loss options?  I'm a true believer in diet and exercise.  When you burn more calories than you consume on a daily basis, the laws of chemistry, physics, and all other natural sciences say that you will lose weight.

There's also the option for gastric bypass, which is really nothing more than a really expensive way to make you stop eating so much.  If you don't exercise while you diet,  or don't continue to exercise after you stop dieting,  your body will eventually slow down its metabolism and weight loss will become harder and harder.   You will gain your weight back.   Some people Many people have literally eaten their way through a gastric bypass procedure and find themselves  right back at square one.

Weight loss is never easy.  You don't get fat overnight.  It takes years of hard work to become a member of the small but growing group of Americans known as the super obese.  Those folks who are so over weight that they literally cannot walk.  These folks can't function.  These folks can't do their activities of daily living.  These folks  have life threatening cardiac and respiratory complications of their eating disorder.  These folks often require an intensive inpatient multidisciplinary team of doctors, nurses, nutritionists, and psychologists to save their life.

So it didn't surprise me when 32 year old  Mrs Smith returned a year later and one hundred  pounds heavier on the doorstep of death. Her 600 pounds was literally crushing her from the outside in.  What was this weight loss option that  failed her so?  In the words of her surgeon:

I offered to refer her to a surgeon who specializes in gastric bypass.  She declined.  I offered to arrange for evaluation of her heart failure and breathing problems.  She declined.  So I gave her a copy of the book "Finding a Thin Person Hiding Inside of You".

It didn't work.  Which makes this the greatest  Fail of weight loss options ever.

For other great weight related posts visit

• How to lose weight after pregnancy (video)
• Try the tongue patch weight loss plan.  
• Losing weight one pound at a time through public display
• Three Clicks Weight Loss Blog.  Unusual motivation to lose weight. 
• My 120 pound journey:  An inspirational weight loss journey.
• One woman's journey to seek out super morbid obesity.

Closet Smokers: They Hold The Key To Cutting Out Of Control Health Care Premiums

You've heard of closet drinkers. This picture below brings new meaning to the term closet smokers. I snapped this picture inside one of the work areas where nurses store all their coats and hats and bags and all their other personal items for the day.  This picture was in fact taken in the nurse lounge in Happy's emergency room.

What we have here is a smoker's closet.  I suppose the ACLU might say it's a  form of closet discrimination in the workplace.  It's an attempt to segregate the smokers from the nonsmokers.  Smoking nurses are a group I will never understand.  Smoking nurses, especially in the emergency room,  are dealing everyday with patients who experience the acute ravishing side effects of smoking induced disease.  

Read On

I Would Like To Thank The Nurses Of Happy's Hospital For An Excellent Job On My Last Night Call

I got about five patient issue calls after midnight, and every single one of them was appropriate for physician night call.  No calls with potassiums of 3.2.  No calls about non critical critical lab values.  No calls about low urine output.   Excellent critical thinking skills all around.  And thank you for calling me on things that matter on the night shift, such as hypotension and respiratory distress.

Thank you.  Thank you.  Thank you.  Let's keep up the great work!

Chiropractic Marketing at Trade Shows and State Fairs: The Great Divide Between Doctors of Medicine and Doctors of Chiropractic

Mrs happy and I went to a local home and garden show this weekend selling everything from landscape rocks to raised garden beds.  The place was packed full of  landscapers, home builders and windows, siding and roofing contractors peddling their goods.  Oh yeah, guess who else decided to show up?  The chiropractors.  That's right.  A  whole slew of chiropractors could be seen hobnobbing with the underground pool contractors and the guy selling lawn furniture made of recycled milk jugs.

Chiropractors are doctors.  They are   doctors of of chiropractic care. So what's up with their chiropractic marketing at  home and garden trade shows and State Fairs?  Why is every street corner now occupied by a chiropractor/massage therapist/acupuncturist?

I'll tell you why.  Chiropractic marketing has infiltrated the public psyche as the people's doctor.  They do things  the public can understand.  They touch you.  They man-ip-u-late you.  The public doesn't understand nor care much about the science.  They care about  the presentation of the science, or pseudoscience.     Chiropractors have learned the marketing skills to  make you want you to pay them cash for their doctoring skills.  They have gained the respect of a nation for their healing hands because their chiropractic marketing techniques make you feel good about who you are.

Chiropractors are  aggressive public marketeers.  Not only are they at every trade show and State Fair, I also see their advertisements all over  radio, television and newspaper platforms.  That's just not something you will  see your local primary care doctor engage in, unless they too are selling you good feelings.  

Chiropractic marketing is all about making you feel good. That's what chiropractic marketing has done for doctors of chiropractic care.  Just as sex sells, so does the  image of chiropractic as a positive life force.  It's all about positive thinking.  It's about wellness.  That's the new buzzword these days in chiropractic marketing.  Everything is now about wellness.  Doctors of chiropractic can charge hundreds of dollars in cash for their ability to make the public feel good about themselves.  Because the public loves feeling good.

But what about the doctors of medicine?  What happened to their marketing skills?  Do they offer wellness?  Do they offer feelings of success and satisfaction?  Well, for the most part, doctors offer scientific reality.  Physician marketing isn't anything like this.    They deal with illness.  They deal with problems that can't be cured by magic zappers and expensive vitamins.  When the public goes to their doctor of medicine, they expect to hear how badly they are doing with their weight or with their diabetes or with their smoking.  They expect to be told they are doing things all wrong.  

And that's where doctors of medicine have failed the marketing success of doctors of chiropractic care.  There's a reason why doctors of medicine don't set up booths at home and garden shows that have been infiltrated by chiropractors.  It's because the public doesn't want to hear the truth about their disease process.  They would rather just feel good.  And ultimately, that's what the public is willing to pay cash for.  And that's the economic lesson that doctors of medicine can learn from their doctor of chiropractic colleagues.

Chiropractors promise you wellness.  But here's a dirty little secret.  You don't have to pay a chiropractor for wellness.  Wellness is achieved by your actions.    Wellness is achieved by the lifestyle you live.  For the most part, it's free.  Chiropractors can't practice medicine.  So they practice wellness.  I consider the chiropractic marketing techniques to be one of the greatest public marketing coup's of the last 100 years.  A campaign that has been built  around the positive aspects of our human existence  rather than the negative aspects of disease management.      And because chiropractic marketing sells  positive excitement, the public is willing to pay an arm and a leg for the chance to feel good again.

Unfortunately, the electric zap gun won't cure your diabetes.  It won't make your cholesterol any better.  It won't keep you from getting pneumonia.  But it will make you believe in yourself.  It will make you feel like a million dollars.   And that's why it's worth a couple hundred.  As for medical doctors?  Often times, medical doctor's have little in the way of hope and excitement to offer their patients.  Death and disease has a way of crashing the wellness parade.  

Chiropractic marketing has cornered the public's limited attention span by laying claim to the Wellness phenomenon sweeping this country. I consider it right up there with the push to limit global warming, the push for renewable energy sources, the push to recycle and the push to be natural in everything we do in our lives.   It seems like every chiropractor's trade show banner presents  their mission as one of wellness.  They don't treat illness.  They promote wellness.   And they do that by zapping your back with magic electricity guns, massage chairs and thousands of dollars worth of expensive natural plant based vitamins to make you high on life.

For medical doctors, what was once considered a noble profession is now vilified in the press.  What was once considered an honor to serve is now considered a right to be taken.  For chiropractors, their ability to market themselves as the people's doctor using a positive platform of wellness and hope has been nothing less than genius.   They have cornered the market on feeling good.  And for those efforts I congratulate them.

Now, if we could only find away to make death and disease glamorous, us medical doctors might be on to something big.

Doctor Humor: (Note to Patients, Medical School Changes Your Doctor)

It's 2:00 am in the emergency room.  That's when the real doctor humor stories comes out to play.  By now  I've sent two patients home from the ER, one of which I spent 90 minutes discussing why chronic abdominal pain management needed to involve an outpatient supratentorial component and why coming into the hospital would be a highly disappointing experience.  

Read On

Severe Scoliosis Picture: I've Never Seen Anything Like This Before

If you've never seen severe scoliosis before take a look at this picture of a CT scan image slice through the abdomen.  For the untrained physician, what you're looking at is just one picture of time and space in the patient's abdomen.

White is bone.  The top bone is the breast bone.  The bottom bones are the spine.    Normally on one picture slice you would only see one vertebrae.  But as you can see, in this patient with severe scoliosis, you can see three vertebrae (the three little box looking things) 

What does this picture tell us?  It tells us that this patient's spine, at some point as it travels from the neck to the butt, is horizontal.  That's right, this patient's severe scoliosis is horizontal to the floor, if they are in the standing position.   That's amazing and painful to look at.   Reminds me of spinal pneumonia".  This patient's severe scoliosis picture  makes that one look like a mild case. This is by far the worst case of severe scoliosis I have never seen.